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Introduction

Effective communication is central to every element of clinical practice from first contact with reception to the point the patient leaves the building. Whilst all team members are aware of the importance of good communication, it is an area that we often overlook in our personal development as clinicians.

For the patient, it is routine to develop trust in the dental team on the basis of their communication skills, where effectiveness in interactions is 'a proxy for clinical expertise'.1 Healthcare educators have known for some time that enhancing clinical communication skills can result in consultations which are more effective, efficient, accurate and supportive.2,3 The GDC's Development Outcome A specifically encourages registrants to update these skills as part of their CPD requirements.4 Clinical communication differs from usual interactions in many ways, including the language we use, the control and dynamics of when the participants take turns to speak, and the different sorts of expertise held by each participant.5,6,7 It also differs in the cultural conventions. For example, in the dental surgery it is expected that one might be asked, and expected to answer, intimate and personal questions by a relative stranger. Clinical communication has been described as similar to intercultural communication: it is inherently like speaking in another language or to someone from another country.8

In dentistry, we routinely need to explain complex procedures and disease processes to patients who are often distracted by anxiety, pain, or a concern about the costs of treatment. The challenge for clinicians to communicate effectively becomes greater in these circumstances. Even prior to the COVID-19 pandemic many patients were having to wait to access routine dental care, and this situation has become more extreme, with large numbers seeking appointments for acute problems.9 Since the Montgomery Supreme Court ruling in 2015, the expectation that indemnifiers and the GDC have is that dental clinicians ensure patients demonstrably 'understand' their treatment options and plan.10,11 These challenges highlight the importance of expert communication in everyday practice which is often characterised by busy working days and relatively brief appointments.

In this short paper we provide some tips and techniques which we have found useful in developing our clinical communication skills, which as with other areas of skill development are a work in progress.

  1. 1.

    Audit your communication

Many clinicians will be already aware of the core clinical communications skills, such as managing expectations, providing jargon-free advice, employing non-verbal communication, and active listening, but when seeing multiple patients day-in and day-out, unwanted habits can form. Ask a colleague or team member to help you audit your communication, or seek specific feedback from patients about your empathy, clarity, and effectiveness.

  1. 2.

    Golden minutes

The first two or three minutes of a consultation are 'golden' for communication, as the patient will often have one or more pressing concerns or anxieties. Prioritise giving focused attention and actively listening to the patient from the first contact - it is a key shortcut to fostering trust,6,12 even in a ten-minute consultation. A good start in the golden opening minutes of interaction can set the tone for the whole patient journey. In 'The Chimp Paradox'13 Steve Peters describes how a bad or incorrect first impression might take seven further encounters to rectify. According to the 'Four Habits Model for Medical Visits' (4H)5 it is important to 'Invest in the beginning', whether it is a new or returning patient, a short or an extended appointment. The better we know our patient, the easier it will be to adapt our communication to their needs - jargon for one may not be jargon for another. Patients often don't reveal all their concerns without prompting14 and eliciting these effectively may result in a shorter appointment15 - a return on your investment. To be prepared to greet each patient with the same level of performance and enthusiasm, consider how you transition emotionally, or 'decompress', between appointments. For some, a short breathing exercise can function like a 'reset' button16 - consider what might be most effective for you. If you are consciously prepared for each patient interaction, you are more likely to respond professionally than to react emotionally.13

  1. 3.

    Be curious, and pause

One consequence of the Montgomery ruling is that dental professionals are required to appreciate the specific preferences and values of their patients, and to ensure that patients understand the options and implications of treatment decisions.10,11 This is potentially challenging when under time pressure and may be most efficiently achieved by being genuinely curious about the patient's life and leaving space for them to tell you. An open question to a patient is most valuable when the clinician then pauses for a response, even if only for a couple of seconds. Research across health disciplines reveals that patients are routinely interrupted when presenting their story, often early in the process.17 This can damage rapport and trust,12 and potentially lengthen the time taken to elicit the patient's concerns and needs. Pausing creates the space for a response but also indicates the expectation of a response. The more engaged the patient is in the interaction, the more likely it will be that they will perceive they have a stake, or control, in the clinical interaction.6,18 Ultimately, giving the patient more space to talk to you without unnecessary interruption will facilitate shared decision making. The empowered patient is also a patient who has taken on more responsibility for decisions made.

  1. 4.

    Is there something else?

Patients will often attend with a shopping-list of queries and concerns. Although there may not be time to address all of them in a single consultation, it is useful to know the full agenda so that appropriate time can be scheduled. Ideally, a well-structured history2 will elicit the full list of concerns, but how we ask questions can directly impact how fully patients express their unmet concerns in primary care.14 In a primary care study by Heritage, it was significantly more effective to ask the patient if there was 'something else' they were concerned about, rather than 'anything else'. 'Anything' appears to cue a 'no' response, 'something' encourages the patient to give you the full shopping-list. Some patients will feel reluctant to ask questions or discuss concerns and so perceiving the clinician as receptive to questions may help. Patients with unmet concerns will tend to feel less satisfied with the encounter.

  1. 5.

    Express yourself, positively

Even as enhanced PPE requirements begin to ease and the COVID-19 pandemic becomes less acute, most of our clinical interactions with patients continue to take place from behind a mask. This restricts the opportunity patients have to receive our intended message, as some of our meaning will be lost with a muffled voice and less visible non-verbal communication. This is exacerbated when we try to explain things while seated behind a supine patient. The net result is that, although we may intend to be empathetic and attentive, the patient may perceive a more blank and emotionless interaction. The solution may be to turn up the volume on how we express ourselves. Vocalise your empathy ('Oh dear!'), be more demonstrative with the encouraging nods, take care with your tone of voice. The usual regulators of conversation are dampened, so our eyes need to work harder to convey empathy. If you are actively listening to a patient, make sure the patient knows: acknowledge both the emotion and the content of their concern.19 When our non-verbal communication is limited, the words we use become correspondingly more important. Framing oral health messages positively may help foster rapport and patient engagement. For example, informing a patient that their gums are '60% plaque-free' might be more encouraging than describing a 'plaque score of 40%', even if the treatment goal is the same.

  1. 6.

    Let me say it again

One of the distinguishing features of clinical communication is the need for repetition. Early research into patients' retention of information suggested that approximately 50% of information provided in a clinical appointment was not retained.20 Of perhaps greater importance now is that patients understand the key information they are given.11 In his book 'Thinking Fast and Slow', Kahneman21 proposes that there are two modes of thinking, and that when under stress we tend to revert to 'fast', intuitive thinking. Thinking in 'fast' mode makes it more challenging to absorb information and to make well-reasoned decisions. Many dental patients are sufficiently stressed (by anxiety, pain, or by undergoing an invasive/operative procedure) to be inclined to fast thinking. Things that help include using clear, simple language, describing the structure of the appointment in advance ('signposting'), and repeating the core information or message.2

  1. 7.

    Did they understand?

The fourth habit in the 4H model is to 'Invest in the End' of the appointment.5 Where you have given important instructions or advice, or have agreed a treatment plan, it is essential to avoid the risk of misunderstandings and miscommunication22 by engaging the patient in dialogue. When information-sharing is an interaction, like a two-way game of frisbee,2 it is easier to encourage the patient to repeat the key information back in their own words to demonstrate understanding. It may be necessary to repeat the information-sharing in a different format (eg, an online video, a printed leaflet, a physical model), or with a different emphasis (visual, auditory etc) but this additional time will be an excellent investment for an effective course of treatment. Take care that any recommended sources of information are accurate and trustworthy. Ask the patient how they would prefer to have things explained, but also try to adapt your explanation to their worldview. For example, one might describe the incidence of anaphylaxis with penicillin (1 in 10,000) roughly in terms of one football supporter in the crowd at a busy Plymouth Argyle football match.

  1. 8.

    The team and triadic communication

The task of effective clinical communication begins at the first point of contact. The entire dental team needs co-ordinated and consistent messaging when interacting with patients. The dental team can also be used more strategically to enhance the engagement of patients in their own treatment conversations (Fig. 1).23 The dental nurse can be an excellent partner when it comes to chairside communication and should be encouraged in this role. A 'triadic' interaction with the patient can see the dental nurse act in a range of communication roles. These can include reinforcing the main message, filling in gaps in information-sharing, or helping engage the anxious or embarrassed patient in interaction.23 Paramedics and emergency care specialists talk 'through' the patient, keeping them involved in the interaction even when they can't actively reply. Calling out notes or a charting to your dental nurse is a great opportunity to indirectly speak to the patient too.

Fig. 1
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Effective clinical communication requires the dental team to engage with the patient (Source: authors)

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  1. 9.

    Relationship-based health-centred dentistry

Theodore Roosevelt is famously quoted as saying 'people don't care how much you know until they know how much you care'.24 When we look at this in the context of dentistry, patients need to have trust and understanding from the professionals that they are encountering, to allow them to get a feeling that we genuinely do care about them. Relationship based health centred dentistry focuses on developing this trust and understanding with patients through our communication with them. One means of creating this trust and understanding is using the tool of co-diagnosis or co-discovery with our patients. This concept can be attributed to the late Dr Bob Barkley, and the work he did around developing the dentist-patient relationship.25 Co-diagnosis is the communication skill of explaining to a patient what you are screening them for and then comparing their diagnosis to health. A good example of this use is when screening the patient for periodontal disease and taking time to explain to the patient what the different codes that you are calling out to your nurse mean - prior to you completing the screening. You do this in layman's terms so the patient can easily understand the different scores, which then helps with the patient 'owning' their diagnosis. Consequences and benefits of treatment are then explained to the patient, which is all tied together with the production of the written treatment plan. This is framed by the patient as the clinician caring about their diagnosis and seen as the clinician wanting to take the patient back to health. With this communication approach, the patient feels that the clinician has taken the time to fully explain the health screening that they have undergone and are more inclined to accept treatment and adopt any behaviour change that is suggested. The patient is more inclined to build a relationship with the dental professional as they feel their individual needs have been catered for.

Conclusions

The classic school-day adage of Festina lente, or 'Make haste slowly', serves as a summary top tip to improve our clinical communication. Create the space for our patients to tell their story. Expect them to be involved in a two-way conversation, and in any decision conversations. Think strategically about how we plan our consultations, deliberately investing time in the beginning and the end. Young or old, experienced or a recent graduate, a periodic audit of performance in communication can benefit every clinician. Those who work in pro-social professions tend to have an aptitude for communicating. The clinical context provides different, specific challenges and consequently these skills need continuous work. As we improve these skills, the evidence suggests that we will gain benefits in time management, engaging our patients in shared decision-making, and smooth, effective practice.